Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
Fragility fracture and secondary prevention
Medicine of older adults · UK scope · Sources checked 27 Aug 2026 · Clinical review pending
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Acute fracture and dangerous secondary causes
Suspected hip fracture, unstable vertebral fracture with neurological deficit, compartment or neurovascular compromise, multiple fractures, hypercalcaemia, unexplained destructive lesion or fracture with constitutional symptoms requires urgent treatment before routine osteoporosis work-up.
Action: Immobilise and handle safely, provide prompt analgesia, assess neurovascular and neurological status, obtain appropriate imaging and urgent orthopaedic or spinal review; investigate malignancy, myeloma, infection or severe metabolic disturbance when the mechanism or imaging is atypical.
Synopsis
Recognise low-trauma fracture as a sentinel event, investigate skeletal and fall contributors without delaying treatment in high-risk people, and deliver coordinated fracture-liaison, osteoporosis, exercise and safety care that prevents the next fracture.
A fragility fracture usually follows force equivalent to a fall from standing height or less and is a clinical signal for prompt secondary prevention.
First-line after acute care is fracture-liaison or equivalent coordinated assessment of fracture site, prior fractures, falls, medicines, nutrition, secondary causes and future risk.
Do not delay treatment simply to obtain DXA when an older person with a recent fragility fracture is already at high or very high risk and treatment is indicated.
Use FRAX or QFracture within its validated population and interpret clinical modifiers; DXA refines risk when it will affect treatment or monitoring.
Vertebral fracture assessment or lateral spine imaging is indicated when height loss, kyphosis, back pain, glucocorticoids or risk suggests occult vertebral fracture.
First-line antiresorptive choices commonly include oral alendronate or risedronate, or intravenous zoledronate when oral administration is unsuitable, selected for renal, gastrointestinal and adherence factors.
Denosumab 60 mg subcutaneously every six months is effective in selected patients but must not be delayed or stopped without a planned alternative antiresorptive strategy.
Very-high-risk disease, especially vertebral fracture burden, may warrant specialist anabolic treatment such as teriparatide followed by antiresorptive therapy.
Correct hypocalcaemia and vitamin-D deficiency before potent antiresorptive treatment and ensure adequate calcium intake, preferably through diet.
Secondary prevention also requires progressive balance and strength exercise, vision and medication review, home intervention and recovery of mobility.
Key red flags
Inability to weight bear or pain on hip rotation after a standing-height fall requires hip-fracture assessment even if the initial radiograph is normal.
New limb weakness, saddle change, sphincter dysfunction or progressive neurological signs with vertebral pain requires emergency spinal imaging.
Night pain, weight loss, hypercalcaemia, anaemia or a lytic lesion suggests malignancy or myeloma rather than uncomplicated osteoporosis.
Fever, recent bacteraemia or immunosuppression with vertebral pain raises discitis or vertebral osteomyelitis concern.
New thigh or groin pain during long-term antiresorptive treatment requires imaging for an incomplete atypical femoral fracture.
Dental infection, severe renal impairment, hypocalcaemia or an unplanned denosumab interruption requires treatment-specific specialist review.
Hip fragility fracture
Groin pain, shortened externally rotated leg or inability to weight bear after low trauma requires urgent hip imaging.
Atypical femoral warning
New persistent thigh or groin pain during long antiresorptive exposure can precede an incomplete femoral fracture.
Pathological fracture pattern
Atypical site, lytic lesion, constitutional symptoms or biochemical abnormalities require malignancy or metabolic evaluation.
Investigation priorities
01
Fracture confirmation and site imagingFirst step
Define the acute injury and stability.
Management branches
First-line post-fracture sequenceTreat promptly during the imminent-risk period
A low-trauma fracture is confirmed or strongly suspected.
Complete acute fracture care and identify previous and occult vertebral fractures, falls and secondary-cause clues.
Estimate risk and obtain DXA only when it will refine management without delaying indicated therapy.
Start appropriate anti-osteoporosis treatment, exercise and falls intervention through fracture-liaison follow-up.
Key medicines
Alendronic acid70 mg orally once weekly; take on rising after an overnight fast with plain water, remain upright and avoid food, drink and other medicines for at least 30 minutes.Avoid with oesophageal emptying disorder, inability to remain upright, hypocalcaemia and severe renal impairment; review dysphagia, upper gastrointestinal symptoms and adherence.
Zoledronic acid5 mg by intravenous infusion once yearly, with infusion duration and renal checks according to the product information.Correct hypocalcaemia and vitamin-D deficiency, ensure hydration, check creatinine clearance and avoid severe renal impairment; acute-phase reaction can follow the first dose.
Sources and review status7 sources · checked 27 Aug 2026 · clinical review pending+
Sources
Sources and review status
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.